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Medicare Part D Prescripton Drug Coverage

Authored By: Georgia Legal Services Program® LSC Funded

FAQ

What is Medicare prescripton drug coverage?

Medicare prescription drug coverage is a new, voluntary benefit under the Medicare program. The Medicare prescription drug coverage program is sometimes called "Part D." Part D benefits will be provided by private insurance companies.

There are 42 Part D plans to choose from in Georgia.

Part D benefits begin January 1, 2006 if you enroll by December 31, 2005.

You can enroll in a Part D plan from November 15, 2005 through May 15, 2006 to obtain Part D benefits in 2006.

Who is eligible for Part D coverage?

Anyone entitled to Medicare Part A or enrolled in Medicare Part B is eligible for Part D benefits.

For example, if you have a Medicare card, you are eligible for Part D.


 

NOTE: To Enroll, you will need to know your Medicare Part A and/or Part B enrollment dates located on your Medicare Card.
If I have Medicaid and Medicare, do I need Part D coverage?

If Medicaid pays for your drugs and you have Medicare, your prescription drug coverage will change on January 1, 2006. At that time, your Medicaid drug coverage will end. Medicare Part D will replace your current Medicaid prescription drug coverage.

IMPORTANT: Medicare is automatically assigning you to one of the Part D drug plans offered in Georgia. You should have received a yellow letter telling you the name of your Part D drug plan.

CAUTION: This Plan may not be the best Part D plan for you! To choose the best plan for you, call the

You can change plans at any time and your new coverage will start the first day of the next month.

If you also have prescription drug coverage from another source, you can learn more below. information.

What if I already have prescription drug coverage from another source?

If you have prescription drug coverage through a private insurance company, or an employer/retiree plan, or VA, or a union plan, or a supplemental (Medigap) policy, you may not need Part D coverage.

You should have received a letter, or a newsletter, or other information from your insurance provider stating whether your prescription drug coverage qualifies as "creditable coverage."

If you have not received a letter describing whether your prescription drug coverage qualifies as "creditable coverage," contact your insurance plan Administrator or Human Resources department.

"Creditable Coverage" means that your other source of prescription drug coverage is at least as good as Part D coverage.

If your current prescription drug coverage qualifies as "creditable coverage," you DO NOT need Part D coverage.

NOTE: If you have Medicaid and Medicare, as well as "creditable coverage" from another source, you MUST disenroll from Part D by calling 1-800-MEDICARE, or by calling the Part D drug plan into which you have been automatically enrolled.
Where do I go for help with Part D?

For more information on Part D:

  • Read the "Medicare & You 2006" handbook that was mailed to you.
  • On the Medicare website you can use the Medicare Prescription Drug Plans page to compare the benefits of different plans in Georgia or use the Formulary Finder to find plans in Georgia that match your required drug list.
  • Call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048 (for the hearing impaired).

For assistance with choosing a Part D plan:

  • Use the Medicare website to find a prescripton drug plan.
  • Call 1-800-MEDICARE (1-800-633-4227), or TTY: 1-877-486-2048 (for the hearing impaired).
  • You can get personal help from the State Health Insurance Assistance Program (SHIP). In Georgia the SHIP is called GeorgiaCares (404-657-5334 or 1-800-669-8387).
  • If you have Medicaid, have your pharmacist call the Medicaid Pharmacy Unit Help Desk at (404) 656-4044 or http://dch.georgia.gov .
  • Call your local Area Agency on Aging at 1-800-669-8387, http://aging.dhr.georgia.gov.
  • For information about qualifying or applying for extra help paying your Part D costs:
  • Call the Social Security Administration at 1-800-772-1213, or
  • Apply on-line, or
  • Visit your local Social Security Administration office in person, or
  • Contact your local Department of Human Services office.
What Part D Plans are available in Georgia?

To learn about the Part D plans in your area:

  • Call 1-800-MEDICARE (1-800-633-4227) to get a list of the specific plans in your area. TTY: 1-877-486-2048 (for the hearing impaired).
How do I enroll for Part D coverage?

First, make a list of your drugs and dosages, as well as your preferred pharmacy. You can find this information on the medicine label, or you can ask your pharmacist to give you this information. After you have completed this step, you are ready to enroll.

There are several ways to enroll:

Visit the official Medicare enrollment site on the web and enroll on-line in a Part D Plan. For information about which Part D plan will best meet your prescription needs, go to Medicare's Formulary Finder on the web.

OR

If you have Medicaid, or Low Cost Drugs for the Elderly and Disabled (DEL), have your pharmacist call the Medicaid Pharmacy Unit Help Desk at (404) 656-4044 or http://dch.georgia.gov .

  • Call your local Area Agency on Aging at 1-800-669-8387, http://aging.dhr.georgia.gov. OR
  • If you have prescription drug coverage through a private insurance company, or an employer/retiree plan, or VA coverage, or a union plan, or a supplemental (Medigap) policy, call:

    • Your plan administrator or your Human Resource Department.

    OR

    If you are unsure about your current prescription drug coverage, or if you need assistance with enrolling, call:

Is there a deadline to enroll for Part D coverage?

Yes. For coverage in 2006, the initial enrollment period is from November 15, 2005 - May 15, 2006.

If you are not yet eligible for Medicare, when you become eligible, you will also be able to enroll for Part D coverage at that time.

For Part D coverage after 2006, the annual enrollment period is from November 15 - December 31.

How much does Part D coverage cost?

There are three categories of out-of-pocket expenses associated with each Part D drug plan: Monthly Premium, Yearly Deductible, and Co-Payments.

The Monthly Premium is the amount you pay each month to the Part D plan for coverage. Each Part D plan has a different Monthly Premium. In Georgia, the Monthly Premiums range from $17.91- $62.29. On the Medicare website you can find the cost of Monthly Premiums of Part D plans offered in Georgia.

The Yearly Deductible is the amount you pay before your coverage begins. This amount is in addition to your Monthly Premium. The amount of Yearly Deductible is $250. This means that for the first $0-$250 of your drug costs, you pay 100%.

A Co-payment is the amount you pay for your prescriptions after you have met the Yearly Deductible amount. Your Co-Payment will vary depending on your total drug costs. In general,

  • When your drug costs are between $251-$2,250, you pay 25% of the costs.
  • When your drug costs are between $2,251-$5,100, you pay all of your drug costs.
  • When your drug costs are above $5,100 in any one year, you pay 5% of the costs, or a co-pay of $2/$5, depending on your Part D plan.

See the chart below.

NOTE: Your costs may be LESS if you qualify for " extra help". See below.

MEDICARE COVERAGE
BASIC BENEFIT FOR 2006
(Amounts do not include Monthly Premiums)

Drug Costs

Medicare Pays

You Pay

0-$250

0

Up to $250

(this is your Yearly Deductible)

$250-$2,250

Up to $1,500

(75% of costs)

Up to $500

(25% of costs)

$2,250-$5,100

0

Up to $2,850

(100% of costs)

Over $5,100

95%

5%, or $2/$5 co-pay

Will Part D pay for all of my prescriptions?

Not necessarily.

Certain types of drugs are not covered by Part D, including:

  • Over-the-counter drugs, with the exception of insulin;
  • Weight-loss and weight-gain drugs;
  • Drugs to relieve cough/cold symptoms;
  • Drugs to promote hair growth;
  • Fertility drugs;
  • Prescription vitamins, with the exception of prenatal vitamins and fluoride;
  • Cosmetic drugs;
  • Drugs that must be monitored by testing services that only the manufacturer provides, such as certain anti-psychotics
  • Barbituates; and
  • Benzodiazapines.
NOTE: If you currently receive prescription drug coverage for any of the drugs listed above through Medicaid or the Drugs for the Elderly and Disabled program (DEL), Medicaid or DEL will continue to pay for these drugs

Even if your drugs do not fall into one of the above categories of excluded drugs, your prescriptions may not be covered by your particular Part D plan. This is because each Part D plan has a unique list of drugs it will cover. A Part D plan's drug list is known as a "formulary."

To find out about which Part D plan's formulary will best meet your prescription needs, go to the Medicare website Formulary Finder on the web,

OR

Call the Georgia State Health Insurance Assistance Program (SHIP) at 1-800-669-8387.

NOTE: If you cannot find a plan that covers all of your drugs, you may be able to enroll in a plan and request an "Exception" to obtain full coverage. For more information, see our Exceptions Q & A below.
What if I can't afford Part D coverage?

If you have limited income and assets (i.e. savings and stocks), you may qualify for "extra help" with the cost of the Monthly Premium, Annual Deductible and/or the Co-Payments.

NOTE: In order to receive "extra help," you MUST APPLY for it, UNLESS you are elderly or disabled AND enrolled in:
  • Medicare and Medicaid, OR
  • Medicare and one of the three Medicare Savings Programs, also known as QMB, SLMB, or QI, OR
  • Medicare and SSI

There are four categories of individuals and/or couples who qualify for "extra help," but must apply to receive it. More on extra help, below.

For information about qualifying or applying for "extra help" paying your Part D costs:

  • Call the Social Security Administration at 1-800-772-1213, or
  • To apply on-line for "Extr Help", visit theSocial Security on-line application siteon the web, or
  • Visit your local Social Security Administration office in person, or
  • Contact your local Department of Human Services office.
My Part D plan denied coverage of my drug. How do I find out why I was denied coverage?

To find out why your prescription was not filled:

  • You could ask the pharmacist for an explanation.

    The pharmacist may or may not be able to explain the reason why you were denied coverage. Depending on the reason for the denial, you may be entitled to request an Appeal or an Exception; to obtain your drug.

    There are several reasons why your Part D plan might refuse to cover your drug. Use the links at the bottom of this page to find out what to do next.

  • If the pharmacist does not give you a reason for the denial, contact your Part D plan and request a "Coverage Determination."

    A "Coverage Determination" is your Part D plan's official decision about the prescription drug benefits you are entitled to receive.

Your request for a "Coverage Determination" must be in writing, UNLESS your health is in serious jeopardy.

See below for more on Expedited Coverage Determinations.

If you need assistance requesting a "Coverage Determination," you can ask your prescribing doctor or someone you trust to request a "Coverage Determination" for you.

NOTE: If someone other than your prescribing doctor is going to request a "Coverage Determination" for you, you will need to submit a written statement to your Part D plan authorizing someone to act for you.

You can get a standard Authorization form from the Social Security website.

What happens next?

Your Part D plan must contact you within 72 hours to explain the reason why it would not cover your drug.

What if I can't wait 72 hours?

You can request an Expedited Coverage Determination.

If you or your doctor believes that waiting 72 hours might seriously jeopardize your health, life, or ability to regain maximum function, you or your doctor can call your Part D plan and request an Expedited Coverage Determination.

Your Part D plan will decide if you qualify for an Expedited Coverage Determination depending on the seriousness of your health condition.

NOTE: Your Part D plan MUST grant a request for an Expedited Coverage Determination if your doctor personally calls your Part D plan and states that waiting 72 hours for a decision might seriously jeopardize your health, life, or ability to regain maximum function.

If your Part D plan grants the request for an Expedited Coverage Determination, it must contact you within 24 hours to explain the reason why it would not cover your drug.

What if the Coverage Determination is unfavorable?

There are several reasons why your Part D plan might refuse to cover your drug. Follow the links below to find out what to do next.

What if my Part D plan determined that my drug was not medically necessary?

First, contact your doctor.

Explain to your doctor that your Part D plan determined that your drug was not medically necessary.

If your doctor believes that your Part D plan's decision is incorrect, you can request an Appeal.

NOTE: You have the RIGHT to request an Appeal.

For questions or advice, call the
Georgia Seniors Legal Hotline at: 1-888-257-9519
or outside Metro Atlanta, contact the local office of Georgia Legal Services Program
that serves your area
.

Your Part D plan's written Coverage Determination will explain how to request an Appeal.

We have more information about the Appeal process below.

What if my drug is not on my Part D plan's formulary?

First, contact your doctor.

Explain to your doctor that your Part D plan refused to cover your drug because it was not on its formulary. Find out whether your doctor will prescribe a substitute drug that is on your Part D plan's formulary.

If your doctor believes that you must have the prescribed drug, then ask your doctor to contact your Part D plan to request an "Exception" and to explain why your drug is medically necessary.

NOTE: You have a RIGHT to request an Exception.

For questions or advice, call the
Georgia Seniors Legal Hotline
at: 1-888-257-9519
or outside Metro Atlanta, contact the
local office of
Georgia Legal Services Program
that serves your area
.

Get more information about requesting an Exception below.

What if I can't get my drug because my doctor did not obtain prior authorization from my Part D plan?

First, contact your doctor.

Explain to your doctor that your Part D plan refused to cover your drug because he/she did not obtain prior authorization. Find out whether your doctor will prescribe a substitute drug that is on your Part D plan's formulary.

If your doctor believes that you must have the prescribed drug, then ask your doctor to contact your Part D plan to request an "Exception" and to explain why your drug is medically necessary.

NOTE: You have a RIGHT to request an Exception.

For questions or advice, call the Georgia Seniors Legal Hotline at: 1-888-257-9519 or outside Metro Atlanta, contact the local office of Georgia Legal Services Program that serves your area.

Get more information about requesting an Exception below.

What if my doctor prescribed a dosage that is not covered by my Part D plan?

First, contact your doctor.

Explain to your doctor that your Part D plan refused to cover your drug because the prescribed dosage is not on the plan's formulary. Find out whether your doctor will prescribe a substitute drug or a different dosage that is on your Part D plan's formulary.

If your doctor believes that you must have the prescribed dosage, then ask your doctor to contact your Part D plan to request an "Exception" and to explain why the dosage is medically necessary.

NOTE: You have a RIGHT to request an Exception.

For questions or advice, call the
Georgia Seniors Legal Hotline
at: 1-888-257-9519 or
outside Metro Atlanta, contact
the local office of
Georgia Legal Services Program
that serves your area
.

Get more information about requesting an Exception below.

What if my doctor prescribed a form (liquid versus pill), or type (generic versus brand) of drug, that is not covered by my Part D plan?

First, contact your doctor.

Explain to your doctor that your Part D plan refused to cover your drug because the form or type prescribed is not on the plan's formulary. Find out whether your doctor will prescribe a different form or type of drug that is on your Part D plan's formulary.

If your doctor believes that you must have the prescribed drug, then ask your doctor to contact your Part D plan to request an "Exception" and to explain why the type or form of your drug is medically necessary.

NOTE: You have a RIGHT to request an Exception.

For questions or advice, call the
Georgia Seniors Legal Hotline
at: 1-888-257-9519 or
outside Metro Atlanta,
contact the local office of
Georgia Legal Services Program
that serves your area
.

Get more information about requesting an Exception.

What if I can't afford my drug?

If you have limited income and assets (i.e. savings and stocks), you may qualify for "extra help" with the cost of your drug.

NOTE: In order to receive "extra help," you MUST APPLY for it, UNLESS you are elderly or disabled AND enrolled in:
  • Medicare and Medicaid, OR
  • Medicare and one of the three Medicare Savings Programs, also known as QMB, SLMB, or QI, OR
  • Medicare and SSI

There are four categories of individuals and/or couples who qualify for "extra help," but must apply to receive it. Visit our Extra Help Q & A to see if you qualify.

If you do not qualify for "extra help," contact your doctor.

Explain to you doctor that you cannot afford your drug. Find out whether your doctor will prescribe a substitute drug that you can afford.

If your doctor believes that you must have the prescribed drug, and there are similar drugs on your formulary that cost less, then ask your doctor to contact your Part D plan to request an "Exception" and to explain why your drug is medically necessary.

NOTE: You have a RIGHT to request an Exception in certain circumstances when you cannot afford your drug.

For questions or advice, call the
Georgia Seniors Legal Hotline
at: 1-888-257-9519 or
outside Metro Atlanta,
contact the local office of
Georgia Legal Services Program
that serves your area
.

Get more information about requesting an Exception below.

"Extra Help" Group Categories for People Who Can't Afford the Plan Premiums

Following are four categories of individuals and/or couples who qualify for "extra help," but must apply to receive it.

NOTE: For purposes of qualifying for extra help, "countable assets" include:
  • Real Estate (other than your primary residence)
  • Bank accounts (checking and savings) and certificates of deposit
  • Investments, including stocks, bonds, mutual funds
  • Individual Retirement Accounts (IRAs)
  • Cash

"Countable Assets" DO NOT include:

  • Your primary residence
  • Personal possessions, such as jewelry and household furnishings
  • Your vehicle
  • Cash value of insurance policies up to $1,500 for an individual and $3,000 for a couple
  • Burial plots

GROUP 1:

You are a Medicare beneficiary and Medicaid pays for your prescriptions:

  • You will NOT have to pay the Monthly Premium for a standard Part D plan,
  • You will NOT have to pay the Annual Deductible, and
  • Your Co-payments will range from $1-$5, depending on your income.

GROUP 2:

You are a Medicare beneficiary

AND

  • Your monthly income is below $1,077 for an individual or $1,444 for a married couple (including individuals who qualify for a Medicare Savings Program, also known as QMB, SLMB, or QI)

AND

  • Your countable assets are worth less than $6,000 for an individual and $9,000 for a married couple,

THEN

  • You will NOT have to pay a Monthly Premium for a standard Part D plan,
  • You will NOT have to pay the Annual Deductible, and
  • Your Co-payments will range from $2-$5.

GROUP 3:

You are a Medicare beneficiary

AND

  • Your monthly income is below $1,077 for an individual or $1,444 for a married couple (including individuals who qualify for a Medicare Savings Program, also known as QMB, SLMB, or QI)

AND

  • Your countable assets are between $6,000 and $10,000 for an individual or between $9,000 and $20,000 for a married couple

THEN

  • You will NOT have to pay a Monthly Premium for a standard Part D plan,
  • You will pay a $50 Annual Deductible, and
  • Your Co-payments will be approximately 15% of your Part D covered drugs.

GROUP 4:

You are a Medicare beneficiary

AND

  • Your monthly income is between $1,077 and $1,197 for an individual or between $1,444 and $1,604 for a married couple

AND

  • Your countable assets are below $10,000 for an individual or below $20,000 for a married couple

THEN

  • You will pay between $0 and 75% of the Monthly Premium of a standard Part D plan, depending on your income (sliding scale),
  • You will pay a $50 Annual Deductible, and
  • Your Co-payments will be approximately 15% of your Part D covered drugs.
What if my Part D plan removes my drug from its formulary?

Your Part D plan must provide written notice to you at least 60 days prior to the effective date of the change in its formulary.

If your Part D plan fails to provide you with written notice of a change in its formulary, it must provide you with a 60-day supply of your drug.

NOTE:Your Part D plan cannot change its formulary from November 15- March 3 of each year.

If your Part D plan fails to provide you with written notice of a change in its formulary, and refuses to provide you with a 60-day supply of your drug, contact:

For questions or advice, call the Georgia Seniors Legal Hotline at: 1-888-257-9519 or outside Metro Atlanta, contact the local office of Georgia Legal Services Program that serves your area.

If you receive notice from your Part D plan, or otherwise find out about formulary change that affects you, contact your doctor.

Explain to your doctor that your drug is no longer on your Part D plan's formulary. Find out whether your doctor will prescribe a substitute drug that is on your Part D plan's formulary.

If your doctor believes that you must have the prescribed drug, then ask your doctor to contact your Part D plan to request an "Exception" and to explain why your drug is medically necessary.

NOTE: You have a RIGHT to request an Exception.

For questions or advice,
call the Georgia Seniors Legal Hotline
at: 1-888-257-9519 or outside Metro Atlanta, contact the local office of Georgia Legal Services Program that serves your area.

Get more information about requesting an Exception below.

Can I get my prescription filled at a pharmacy that is not within my Part D plan's network?

You may be able to obtain your drug from a non-network pharmacy, BUT ONLY IF:

  • You cannot reasonably be expected to obtain your drug at a network pharmacy,

    And

  • You do not use a non-network pharmacy on a regular basis.

Otherwise, your Part D plan can refuse to cover your prescription at a non-network pharmacy.

NOTE:If you obtain your drug from a non-network pharmacy, you may be required to pay the difference between the non-network pharmacy's price and your Part D plan's allowance.

For questions or advice, call the
Georgia Seniors Legal Hotline
at: 1-888-257-9519 or
outside Metro Atlanta, contact
the local office of
Georgia Legal Services Program
that serves your area
.

What if my drug is not covered by Part D?

You may need to pay out-of-pocket for drugs specifically excluded from Medicare Part D coverage, which include the following:

  • Over-the-counter drugs, with the exception of insulin;
  • Weight-loss and weight-gain drugs;
  • Drugs to relieve cough/cold symptoms;
  • Drugs to promote hair growth;
  • Fertility drugs;
  • Prescription vitamins, with the exception of prenatal vitamins and fluoride;
  • Cosmetic drugs;
  • Drugs that must be monitored by testing services that only the manufacturer provides, such as certain anti-psychotics;
  • Barbituates; and
  • Benzodiazapines.

However, you may be able to purchase an enhanced Supplemental Medicare Prescription Drug Plan that offers coverage for the above non-covered drugs.

Call your local Area Agency on aging at 1-800-669-8387, http://aging.dhr.georgia.gov.

NOTE: If you currently receive prescription drug coverage for any of the drugs listed above through Medicaid or the Drugs for the Elderly and Disabled program (DEL), Medicaid or DEL will continue to pay for these drugs.

For questions or advice, call the
Georgia Seniors Legal Hotline
at: 1-888-257-9519 or
outside Metro Atlanta, contact
the local office of
Georgia Legal Services Program
that serves your area
.

Can I Change Plans?

If you enrolled in a Part D plan that you are not happy with or if the plan is not meeting your prescription and other medical needs, you may be able to change from one plan to another, but only during certain times.

You have the following options:

In 2006, if you enroll in a Part D plan by May 15, 2006, you may be able to switch plans once before June 30, 2006.

You can also switch plans each year during the Annual Election Period (AEP), generally between November 15th and December 31st.

NOTE:If Medicaid pays for your drugs, or if a Medicare Savings Program pays your Medicare Part B premiums, you may switch plans at any time, and your new coverage will become effective the following month.

Call your local Area Agency on Aging at 1-800-669-8387, or visit http://aging.dhr.georgia.gov.

How do I request an exception?

Contact your Part D plan to request an Exception.

Your request for an Exception must be in writing, UNLESS your health is in serious jeopardy.

Learn about Expedited Exceptions below.

You have the RIGHT to request an Exception when:
  • Your drug is not listed on your Part D plan's formulary, or
  • Your doctor fails to obtain prior authorization from your Part D plan to prescribe the drug to you, or
  • Your doctor prescribes a dosage that is not covered by your Part D plan, or
  • Your doctor prescribes a form (liquid versus pill), or type (generic versus brand) of drug that is not covered by your Part D plan, or
  • When your Part D plan removes your drug from its formulary, or
  • When you cannot afford the co-payment for your drug and your Part D plan offers other drugs at a lower price

If you need assistance requesting an Exception, you can ask your prescribing doctor or someone you trust to request an Exception for you.

NOTE: If someone other than your prescribing doctor is going to request an Exception for you, you will need to submit a written statement to your Part D plan authorizing someone to act for you.

You can get the standard Authorization form from the Social Security website.

IMPORTANT:To request an Exception, your prescribing doctor MUST contact your Part D plan and state why your drug is medically necessary.

What happens next?

Your Part D plan must contact you within 72 hours after it receives your doctor's statement to explain its decision.

What if I can't wait 72 hours?

You can request an Expedited Exception.

If you or your doctor believes that waiting 72 hours might seriously jeopardize your health, life, or ability to regain maximum function, you or your doctor can call your Part D plan and request an Expedited Exception.

Your Part D plan will decide if you qualify for an Expedited Exception depending on the seriousness of your health condition.

NOTE: Your Part D plan MUST grant a request for an Expedited Exception if your doctor personally calls your Part D plan and states that waiting 72 hours for a decision might seriously jeopardize your health, life, or ability to regain maximum function.

If your Part D plan grants the request for an Expedited Exception, it must contact you within 24 hours after it receives your doctor's statement to explain its decision.

What if the Exception decision is unfavorable?

Contact your doctor to discuss the decision. If your doctor believes the decision is incorrect, you can request an Appeal.

NOTE: You have the RIGHT to request an Appeal.

For questions or advice, call the
Georgia Seniors Legal Hotline at: 1-888-257-9519
or outside Metro Atlanta, contact the local office of Georgia Legal Services Program
that serves your area
.

Your Part D plan's written Exception decision will explain how to request an Appeal.

We have more information about the Appeal process below.

How do I file an appeal?

To make your first Appeal, you must submit a written request to your Part D plan.

Your first Appeal is called a Redetermination.

You will have 60 days from the date on the written notice of the Coverage Determination or Exception decision to submit a request for Redetermination.

What do I include in my Appeal?
You should include your name, address, Member ID number, the reasons for appealing, and any evidence you wish to attach. This may include evidence that your drug is medically necessary.

What happens next?

Redeterminations must be decided and implemented within 7 days after your Part D plan receives the request for Redetermination.

What if I can't wait 7 days?

You can request an Expedited Redetermination.

If you or your doctor believes that waiting 7 days might seriously jeopardize your health, life, or ability to regain maximum function, you or your doctor can call your Part D plan to request an Expedited Redetermination.

Your Part D plan will decide if you qualify for an Expedited Redetermination depending on the seriousness of your health condition.

NOTE: Your Part D plan MUST grant a request for an Expedited Redetermination if your doctor personally calls your Part D plan and states that waiting 7 days for a decision might seriously jeopardize your health, life, or ability to regain maximum function.

If your Part D plan grants the request for an Expedited Redetermination, it must contact you within 72 hours to notify you of its Redetermination decision.

What if the Redetermination decision is unfavorable?

If the Redetermination decision is unfavorable, you have the RIGHT to request the next level of Appeal.

Call your local Area Agency on Aging at 1-800-669-8387, http://aging.dhr.georgia.gov.

NOTE: Your Part D plan's written Redetermination decision will explain how to request the next level of Appeal, which is called Reconsideration.
Last Review and Update: Feb 16, 2006